Surgical Procedures: Surgery and Staging for Rectal Cancer

The rectum is at the end of the colon. It is about 5 inches long. It is where stool sits before it exits your body. When there are cancer cells in the rectum, it is called rectal cancer.

Rectal cancers often start in precancerous polyps of the rectum. These are called Adenomatous polyps. They can turn into cancer and can grow into the rectal wall. Other less common types of rectal cancers are:

• Carcinoid tumors.
• Gastrointestinal stromal tumors (GISTs).
• Lymphomas.
• Sarcomas.

What is staging and how is it done?

Staging is a way to find out if and where the cancer has spread in your body. Your provider will have you get a few tests to figure out the stage of your cancer. For rectal cancer, these tests may be:

Physical Exam: This is an exam to look at your body and to talk about past health issues.

Imaging: Radiology tests can look inside your body at the cancer and see if it has spread. These tests are:

• X-ray.
• CAT scan (CT scan).
• Positron emission tomography scan (PET scan).
• Magnetic resonance imaging (MRI).
• Endorectal/transrectal ultrasound.

Laboratory Testing: Blood tests such as blood chemistry, a complete blood count, CEA (carcinoembryonic antigen) assay, and testing for blood in the stool may be done.

Procedures: Each case of rectal cancer is different. Talk with your care team about which procedures may be part of your treatment plan. These options may be:

• Fecal Occult Blood Testing: Also known as guaiac-based fecal occult blood test (gFOBT) and fecal immunochemical test (FIT). These test for blood in the stool.
• Stool DNA testing: This test looks for abnormal DNA found within the stool.
• Blood testing: Your healthcare team may want to test your levels of carcinoembryonic antigen (CEA) in your blood, which may be tested and tracked over time.
• Colonoscopy: A colonoscope (lighted, flexible tube) is inserted into the rectum, reaching the whole colon to check for any changes or polyps. A biopsy may be done during this test.
• Sigmoidoscopy: A sigmoidoscope (lighted, flexible tube) is inserted into the rectum and the lower part of the colon (called the sigmoid colon) to look for any changes. A biopsy may be done during this test.
• Double-contrast barium enema (Lower GI series): This test uses the liquid enema contrast barium which is put into your rectum. It helps to show any abnormalities on X-rays taken of the lower gastrointestinal tract which includes the colon and the rectum.
• Biopsy: Biopsies may be taken to check for cancer. Your provider may also want to check for a genetic mutation called hereditary nonpolyposis colorectal cancer.

Rectal cancer spreads to other parts of the body through the tissue, lymph, and blood systems. Cancer stage describes how extensive the cancer, how far it has spread and helps guide your treatment. Rectal cancer is described as stages 0 through stage IV (4) disease.

Often, you will need surgery if you have rectal cancer.

Surgical Procedures for Rectal Cancer

There are a few surgical procedures used to treat rectal cancer, depending on your cancer stage and overall health, such as:

• Polypectomy/Local excision: A colonoscope (like with a colonoscopy) is used to remove a polyp or an area of cancer. During a polypectomy, only the polyp is removed. During a local excision (also known as an endoscopic mucosal resection), some of the tissue on the rectal wall is also removed.
• Local transanal resection (Full thickness resection): The cancer is removed from the rectum, as well as some nearby healthy tissue through the anus. Some lymph nodes and the tissue between the rectum and abdominal (belly) wall may be removed. In some cases, the surgeon may use a magnifying scope to perform a transanal endoscopic microsurgery (TEM).
• Low anterior resection (LAR): The cancer is removed from the upper part of the rectum. Some healthy tissue and lymph nodes are also removed for testing. The colon and rectum are then re-connected. Sometimes a temporary ileostomy will be done to allow for healing.
• Abdominoperineal resection (APR): The anus, anal sphincter and nearby tissue are removed. You will need a permanent colostomy.
• Proctectomy with colo-anal anastomosis: The whole rectum is removed, connecting the colon directly to the anus. At times, surgeons will create a pseudo rectum using a part of the colon that will then store fecal matter to exit the body. In some cases, there is a need for a temporary ileostomy.
• Radiofrequency ablation: Electrodes kill cancer through a probe inserted through the skin or an abdominal incision.
• Cryosurgery: Abnormal cells are frozen and killed.
• Pelvic exenteration: Removes the rectum, bladder, prostate in men or uterus in women. You will need a colostomy to remove stool and at times a urostomy to remove urine.
• Diverting colostomy: A rectal blockage can be relieved by placing a diverting colostomy (ostomy placed above the tumor in the GI tract).
• Surgery for metastatic disease: At times, rectal cancer may spread to other parts of the body, such as the lungs or liver, and it may need to be removed. These procedures depend on several factors that your healthcare provider will talk with you about.

Note: Your surgeon may consider minimally invasive surgery with laparoscopy or robotic surgery. There is also an option for nerve-preserving surgery, which aims to keep urinary and sexual function. Ask your provider which type of surgery is best for you.

What are the risks of rectal cancer surgery?

As with any surgical procedure, there are risks and side effects linked with rectal cancer surgery. These risks and side effects may be:

• Reaction to anesthesia (Anesthesia is the medication you are given to help you sleep through the surgery, not remember it and to manage pain).
• Bleeding.
• Blood clots.
• Infection.
• Anastomotic leak (leakage from the joined colon or anastomosis site).
• Pulling apart or splitting open of the incision.
• Adhesions/scar tissue.
• Bowel obstruction (blockage).
• Need for colostomy or ileostomy, which can affect body image.
• Possible erectile dysfunction, orgasm changes, and impaired fertility in men.
• Possible painful intercourse and loss of ability to carry a child in women.

What is recovery like?

Recovery from rectal cancer surgery depends on the procedure that was done. A hospital stay is often needed.

You will be taught on how to care for your surgical incisions and/or ostomy and will be given any other instructions before leaving the hospital.

Your medical team will talk with you about the medications you will be taking, such as those for pain, blood clot, infection, constipation prevention and/or other conditions.

Your healthcare provider will go over any changes in your activity level depending on the surgery you have had. You will be given instructions on when to call your healthcare team.

What will I need at home?

• Thermometer to check for fever which can be a sign of infection. Your provider will tell you at what temperature you should call them.
• Loose clothes and underwear.
• Incision and/or ostomy care items, often supplied by the hospital/physician office.

How can I care for myself?

Depending on the extent of your surgery, you may need a family member or friend to help you with your daily tasks until you are feeling better and your medical team gives you the go ahead to resume normal activity.

Be sure to take your medications as directed to prevent pain, infection or other conditions and call your medical team with any concerning symptoms.

If constipation is present, speak with your healthcare team about recommendations they have to offer relief.

Deep breathing and relaxation are important to help with pain, keep lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to perform deep breathing and relaxation exercises several times a day in the first week, or whenever you notice you are particularly tense.

• A simple exercise to do on your own: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.

This hand-out provides general information only. Please be sure to discuss the specifics of your surgical plan and recovery with your surgeon.